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Survey shows improving communication, but highlights concerns about pain control and information given at discharge

Patients rate highly the care they receive in NHS A&E departments, with 88% rating it as “excellent”, “very good” or “good”, according to a survey published today (Wednesday) by the Healthcare Commission.

The survey also shows that 69% of patients who travelled to A&E in an ambulance rated the care they received from the ambulance staff as “excellent”.

The survey included responses from just under 50,000 patients over age 16 who had visited an A&E or emergency department between January and March 2008. It was coordinated for the Commission by the Picker Institute and carried out by 151 hospital trusts. The Commission is
today publishing on its website results for all trusts including scores for each question.

The survey shows improvements in communication since it was last carried out in 2003 and 2004. More patients said that they definitely had enough time to discuss their problem (69% up from 62% in 2003), and that they were definitely listened to by doctors and nurses (76% up from 73% in 2003).

But the survey results also highlight some key areas of concern.

The survey shows that 59% of people said staff definitely did everything they could to help control pain, a further 27% said they did to some extent and 14% said they did not. This shows some progress since 2003 and 2004, but the Commission says further improvement is needed in this area as a whole. Separately, the Healthcare Commission’s recent review of urgent and emergency care showed wide variations in whether A&E units met the guidance for the timescale within which pain relief should be given to children with a fractured limb.

In addition, many patients said they do not get enough information when they leave A&E. Only about a third (37%) said they were given a complete explanation of possible side effects of their medication, up from 35% in 2003 and 36% in 2004. And only 37% said they definitely received information about when they can resume activities such as driving or going back to work, up from 35% in 2004.

Around half of patients went to A&E by car, yet one in four people found it difficult to find a convenient place to park on arrival.

While 98% of patients waited less than four hours to be examined by a doctor or nurse, 27% said their overall visit to the emergency department lasted longer than four hours. The Commission believes this may be because some A&E departments have admissions units which are used to determine if a patient should be admitted to an inpatient ward or discharged.*

The four-hour national target is only applicable to A&E departments, not admissions units, and patients are unlikely to be aware of the difference when responding to the survey. In its recent review of urgent and emergency care services, the Commission called for a review of urgent care targets. It advocates performance measures that look at the whole system rather than its constituent parts. It believes it would be preferable to measure performance from the time a patient seeks emergency care to the time they receive it, not just the time the ambulance takes to reach a patient and the time spent in A&E.

Anna Walker, the Commission’s Chief Executive, said: “It is good to see that so many patients are so positive about their care by ambulance staff and in A&E and that there have been improvements in communication, particularly as a visit to A&E will be an anxious time for many. These achievements come against a backdrop of significant rises in demand for A&E services.

“But patients have raised important issues about staff helping to control pain, the information patients are given on discharge, privacy when they book in at reception and access to help when needed. This is important feedback that trusts should listen to. We hope all trusts will compare their results with others and act to ensure they match the best.

“Understanding and responding to experiences of patients is critical in a modern NHS.”

The survey found that:

· Overall, patients were positive about the standard of care in A&E departments with 88% of patients rating their care as ‘excellent’, ‘very good’, or ‘good’. More people rated their care as ‘excellent’ this year – 35% up from 31% in 2003 and 34% in 2004. Almost three quarters of people (73%) said theydefinitely had confidence and trust in the doctors and nurses examining and treating them and 22% said they did to some extent. Of those who travelled to A&E in an ambulance, 78% said the ambulance crew definitely explained their treatment in a way they could understand, 18% said they did to some extent, and 4% said they did not.

· Results show improvements in communication with staff. Sixty-nine percent said they definitely had enough time to discuss their health or medical problem with staff, up from 62% in 2003 and 66% in 2004. Seventy-six percent said that doctors or nurses definitely listened to them (up from 73% in 2003 and 74% in 2004). Fifty-three percent said that a doctor or nurse discussed completely any anxieties or fears they had about their condition or treatment, an increase from 49% in 2003 and 51% in 2004.

· Progress has been made with regard to staff helping to control patients’ pain, but there is still room for improvement. Of those who experienced pain, 59% thought staff definitely did everything they could to help control it, up from 56% in 2004 and 55% in 2003. Twenty-seven percent said staff did all they could to control pain to some extent, and 14% said they did not.

· The survey showed some improvement in provision of information on discharge, but too many people said they left A&E without all the information they needed. Eighty four percent of respondents who were prescribed new medication before leaving the emergency department said the purpose of medication was fully explained to them, up from 82% in 2003 and 81% in 2004. Just over a third (37%) said they were given a complete explanation of possible side effects of their medication (35% in 2003 and 36% in 2004). Of those who needed information about when to resume usual activities – such as going back to work or driving a car – only 37% said they definitely received it (35% in 2004). Almost two thirds of respondents (65%) said that a member of staff told them what danger signals to watch for after they went home, either completely or to some extent. This leaves over a third of people who said they were not told what danger signs to look out for after they have left A&E (35%).

· There have been no significant improvements since 2004 in patients’ views on cleanliness of departments. Less than half of respondents (44%) rated the emergency department as very clean - no change since 2004 but a decrease from the 2003 survey (48%). Forty seven percent rated the emergency department as fairly clean (46% in 2004). Nine percent rated the department overall as not very clean or not at all clean. Of those who used the toilets, 38% rated them as very clean and 16% reported that they were not very clean or not at all clean. This shows no change since 2004, but is a decrease from the 2003 survey, where more respondents rated the emergency room toilets as very clean (43%) than fairly clean (42%).

· There were areas where improvements could be made relating to respect and dignity. Although a majority (79%) said that they were definitely given enough privacy when being examined or treated, this decreased slightly from 80% in 2004. When booking in at reception, only 41% of patients said they were ‘definitely’ given enough privacy to discuss their condition. A further 44% said they had only been given enough privacy to some extent. There was a decrease in the proportion of patients saying they were always able to get a member of staff to help them if they needed attention, down to 55% from 57% in 2004. Seventy eight percent said they had been treated with respect and dignity all of the time, a decrease from 79% in 2004.

· There has been a decline in the number of patients who felt they were involved in decisions about their care as much as they wanted to be. Of those respondents well enough to be involved in decisions about their care and treatment, 62% said they were definitely involved as much as they wanted to be, a decrease from 64% in 2004 and 63% in 2003. Over three quarters of respondents (77%) said they were given the right amount of information about their condition or treatment, an increase from 75% in 2003. Fifteen percent said they did not get enough information and 7% said they were not given any, unchanged since 2004.

· The survey suggests that respondents felt they waited longer at various stages of their care than in 2004. Forty percent of people reported that they first spoke to a health professional within 15 minutes of arriving at the emergency department, down from 47% in 2004. Fewer said they were examined by a doctor or nurse within an hour of arrival in 2008 (73%), a rise from 66% in 2003 but a fall from 2004 (74%). The proportion of respondents saying they stayed in the emergency department for four hours or less fell from 77% in 2004 to 73% in 2008, although this is an improvement from 68% in 2003. Of those who waited to be examined by a doctor or nurse, more than half (56%) said they had not been told how long they would wait. This has not changed since 2004 but is an improvement on 58% in 2003.



Notes to editors:

What the Commission is publishing

In publishing the results of the accident and emergency patient survey, the Commission has released the following:

· A briefing note outlining the national results, indicating where there have been statistically significant changes over time

· A document containing tables that compare the results for each question with previous survey results, identifying the statistically significant changes

· A benchmark report for each trust, in pdf format, containing standardised scores. For most trusts, their results are standardised to all respondents and their scores are presented against those from all other trusts. Please note the benchmark reports for non specialist trusts in London are, standardised to the London respondents. This presents the score for each London trust against those from all other trusts in London rather than England as a whole (see ‘London trusts’ below for an explanation).

· A comparative scores workbook (excel) containing the standardised scores from the benchmark reports for all trusts. This can be used as an overview to compare results between all trusts.

· An additional comparative scores workbook (excel) containing the standardised scores from the benchmark reports for every trust in London. This can be used as an overview to compare results between London trusts.

· A guide to the comparative scores workbooks

· A spreadsheet containing the actual percentage responses for each question for each trust. This contains non-standardised data and should not be used to compare trusts.

How to use the scored comparative information

The benchmark reports are produced for trusts to allow them to identify their position in comparison with other, similar, trusts, and can be used to examine an individual trust’s performance on the survey. These also contain information on how to interpret the charts displayed within the reports.

The colour-coded comparative scores workbooks (excel) contain the same data as the benchmark reports, and can be used to gain a quick indication of patients' reported experiences at a trust relative to other, similar trusts. A green code indicates that the trust's average score was in the top 20% on a particular question and red indicates performance in the bottom 20%. Caution should be used when interpreting these, as trusts with different colour codes may be very similar once confidence intervals (estimates of reliability) are taken into account. Furthermore, if many trusts score highly on a particular question, a score in the bottom 20% may still be a high score or vice versa where many trusts score poorly.

The workbooks also include 'confidence intervals' - estimates of reliability - for each of the scores. They show how confident we can be that a trust is within a particular range of performance. The score is less reliable where the confidence intervals are wider.

The scores also allow comparisons between trusts, taking into consideration the confidence intervals. Where there is no overlap between the confidence intervals for two trusts, the trusts’ scores are significantly different - that is, we are confident they are not simply due to chance. Because confidence limits often do overlap, and many trusts are therefore similar, the scores are not suitable for producing league tables.

The spreadsheet containing percentage results should not be used for comparisons across trusts. This is because the data is non-standardised, i.e. it has not been adjusted to take into consideration the age and sex of respondents at each trust, and it does not include confidence
intervals.

Further information on interpreting the data is available in the guide to comparative scores workbook.

London trusts

There is evidence that responses to patient experience and other public service user surveys vary geographically, especially in relation to London trusts, which tend to have poorer results. The Healthcare Commission has investigated this feature and has identified a number of factors that might be associated with it. This may be explained by real differences in the experiences of service users in London, differences in expectations, or other factors (such as ethnic diversity, transient populations and staffing difficulties) - or it may be some combination of these factors. The Commission is continuing to investigate this, although the issue is very complex and the exact reasons for variation difficult to establish. However, we can be sure at this stage that trusts are not unduly penalised in the Annual Health Check as a result of their patient survey data.

A&E services in London also face particular challenges such as the size, diversity and mobility of the population they serve. Figures from the Commission’s recent urgent and emergency care review showed there are a higher number of visits to A&E services in London than in other parts of the country. NHS London (the Strategic Health Authority) is encouraging growth in primary and community care services in order to ease pressure on A&E services in London.

Given these factors, the Commission has published two sets of comparative scores for London trusts, in the form of two excel workbooks. One workbook includes the scores for all trusts in England, including London trusts, compared against the whole of the country.

In the other workbook, London trusts are scored based on a comparison only with other London trusts. This means the scores will be slightly different. The scores in the London-only comparative workbook are the most appropriate to use for London trusts, given the issues described above (see the ‘guide to comparative scores workbook’ for more information).

The Commission will continue to explore other options for presenting survey data in the future, to ensure that every set of data is presented in the most effective way.

Waiting times

* The Commission points out that the increase in the time patients say they spent in A&E may reflect changes in the way departments organise themselves.

Many trusts have introduced admissions units, which are used to determine if a patient should be admitted to an inpatient ward or discharged. The four-hour national target is only applicable to A&E departments, not admissions units, and patients are unlikely to be aware of the difference when responding to the survey. In addition, children are often fast-tracked through the system and children (aged under 16) are not included in this survey.

Approximately 19 million people attended an A&E department in 2007/08. The Commission’s annual health check results showed that for the first time in three years trusts fell short of the target for treating 98% of patients within four hours, at 97.9% nationally. This was also reflected in the Commission’s recent review of urgent and emergency services.

Information on the Healthcare Commission
The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.


The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.

For further information contact the press office on 0207 448 9401, or on 07917 232 143 after hours.